Abstract

Contemporary researchers have tended to examine dysfunction among the lives of persons with schizophrenia as a matter of the impact of biological and social forces. While this has greatly advanced the knowledge base, any account of schizophrenia without a full consideration of the illness's first-person dimensions risks missing that schizophrenia is a disorder that interrupts the lives of people who must continue to struggle to find and create security and meaning. While literature from a range of sources has explored self-experience in schizophrenia, one barrier to the creation of a larger synthesis and application of this work is that it remains unclear whether, and to what degree, these differing views of self-experience are comparable with one another. To address this issue, this article reviews 6 different accounts of self-experience, a fundamental, first-person dimension of schizophrenia. The 6 are early psychiatry, existential psychiatry, psychoanalysis, phenomenology, psychosocial rehabilitation, and dialogical psychology. After comparing and contrasting the 6, we conclude that there is a wide-ranging, if general consensus, which suggests that many suffering from schizophrenia experience themselves as diminished relative to their former selves, ie, after onset they experience themselves as less able to engage the world effectively, which intensifies their anxieties in the face of everyday interactions. However, within this broad consensus, significant disagreements exist around issues such as whether these difficulties meaningfully predate the illness, how recovery is possible, and if so, under what conditions. In closing, we suggest a program of research to address these disagreements.

Dysfunction among persons with schizophrenia, while more and more a matter of careful research and study, has been principally examined as a matter of biological and social forces influencing individual lives. Aberrant neurodevelopment1,2,3 and neurodegenerative processes, for instance,4,5,6 have been widely discussed as central to prolonged dysfunction in schizophrenia, as have stigma,7,8 social marginalization,9 and childhood trauma.10,11 These views, which proceed from a third person perspective, have informed both theory and practice and greatly broadened our contemporary understandings of disability. Nevertheless, an account of schizophrenia that fails to consider the illness's first-person dimensions is incomplete. Schizophrenia is a disorder that interrupts the lives of people who must continue to struggle to find and create security and meaning in a world of contingency, and these struggles, as well as the experiences they address, should be acknowledged and explored. As Stanghellini12 suggests, a failure to do so may amputate “madness from the man who embodies it” (p46). And as Barham13 notes, if we do not engage a person with schizophrenia “… as an active participant in social life” we may be unable “to identify more adequately where (at points) he fails as a social agent” (p78). Finally, overlooking schizophrenia's first-person dimensions also risks objectifying persons with it. And, to the degree that we unwittingly identify those persons with wholly impersonal conditions, we risk erasing from view whatever capacities they have that might enable them to productively interpret and address their illness.

While the majority of the literature seeks an increasingly complete third person account of dysfunction in schizophrenia, considerable work does exist that explores dysfunction's first-person facets. For one, a wide literature has suggested that schizophrenia involves alterations in self-experience, ie, in how persons experience themselves in the course of their many pursuits and relations. Andresen and colleagues,14 in a review of reports about recovery from schizophrenia, including a large number of first-person accounts, note that 42 of 46 articles reviewed mention that “loss of a sense of identity” is a key aspect of the illness (p589). Consistent with this, first-person accounts by individuals with schizophrenia describe anguished alternations in basic experience. Deegan,15 for instance, wrote: “My world sometimes felt like a distorted house of mirrors reflecting infinitely inward upon itself” (p369). Similarly, Fowler16 declared: “At first I just thought it was different moods, but now it's more than that … my personality is somehow unraveling” (p17).

Considering these matters, Davidson17 has suggested that many with schizophrenia experience themselves as (a) lacking a story of their own and (b) not being worthy of such a story, as if their lives were not worth synthesizing or recounting. Sass18 has suggested that schizophrenia involves an alienating, extreme form of self-awareness. Very recently, Uhlhaas and Mishara19 have used a phenomenological account of self-experience in schizophrenia to better understand the emergence of delusions, just as Stanghellini and Ballerini20 have employed phenomenological accounts to understand social and occupational dysfunction. Bell et al21 have explored how enhancements in neurocognitive capacities may enable greater function in part because they broaden the richness of first-person experience.

One barrier, however, to the creation of a larger synthesis and application of the work on first-person experience in schizophrenia is that it remains unclear whether, and to what degree, these views are comparable with one another. In what ways, for instance, are Sass18 and Davidson describing the same or different phenomena? And because Davidson22 has distanced his methodology from psychoanalysis, how do rehabilitation and psychoanalytic observations of self-experience in schizophrenia compare? Stanghellini and Lysaker23 have pointed out how phenomenological accounts of first-person experience in schizophrenia indicate very different treatment implications than those of cognitive behavioral therapy. What does this suggest about their respective conceptions of self-experience in schizophrenia? In short, a synthetic presentation of the key points of agreement and disagreement among different theorists from different schools is lacking. Indeed it is not uncommon for explorations of self-experience to not only fail to contrast their views with others but also virtually ignore the claims of others.

In order to help establish a common discourse regarding these issues, the current article will review 6 different accounts of a fundamental, first-person dimension of schizophrenia, namely, self-experience. For our purposes, self-experience involves (a) an awareness of one's self or better yet, the experience of finding oneself, (b) as a particular kind of person in a particular situation, and (c) faring more or less well. For example, one might find oneself faring poorly as a husband, or in harms way while walking home, or lost in the midst of a midlife crisis. In sum, self-experience names the sense one has of one's character and relative welfare in the course of one's life.

Our review will engage 6 different perspectives: early psychiatry, existential psychiatry, psychoanalysis, phenomenology, psychosocial rehabilitation, and dialogical psychology. Of note, our primary goal is not to provide a thorough overview of each; that could easily fill several volumes. Instead, we wish to highlight key points of convergence and divergence and to propose concrete research questions for future work, which might complement social and biological lines of inquiry into schizophrenia.

Views of Self-experience in Schizophrenia From Early Psychiatry

Most agree that Bleuler24 and Kraepelin25 were the first to systematically catalogue and organize the discrete manifestations of schizophrenia. They distinguished major symptoms and proposed models regarding the course of illness. They also observed various kinds of self-experience accompanying schizophrenia. After a lengthy apology and explanation for his decision to create the term “schizophrenia,” Bleuler,24 in Dementia Praecox or the Group of Schizophrenias, observes in a section labeled “The Definition of the Disease”: “If disease is marked the personality loses its unity … one set of complexes dominates the personality for a time, while other groups of ideas or drives are ‘split off’ and seem either partially or completely impotent.”24(p9) Later, discussing what he labeled accessory symptoms (eg, hallucinations and delusions), he adds: “Everything may seem different; one's own person as well as the external world … in a completely unclear manner so that the patient hardly knows how to orient himself either inwardly or outwardly …. The person loses his boundaries in time and space” (p143—italics added).

Kraepelin25 devoted very little space to self-experience, but he nevertheless seemed to presume that the dissolution of self-experience is a fundamental aspect of the disorder. For instance, he notes in the first sentence of his 191925 considerations: “Dementia praecox consists of a series of states, the common characteristic of which is a peculiar destruction of the internal connection of the psychic personality” (p3). Moreover, given his focus on schizophrenia as the loss of drive, interest, and affect, his work can be read as a portrait of a ruined subjectivity. These early views suggest, then, that schizophrenia often involves profoundly disorganized and unstable psyches and that such disturbances lead to skewed and difficult relations with oneself and others. Though these phenomena are still observed from the third person, ie, neither approach the phenomenon from the vantage point of one undergoing and responding to it, both suggest that the disorder undermines the meaning-making capacities of those afflicted.

Views of Self-experience in Schizophrenia From Existential Psychiatry

One of the most popular figures to comment on self-experience in schizophrenia is Laing,26 who called for a radically existential redetermination of notions regarding mental illness. Despite his opposition to many of the tenets of traditional psychiatry, his observations in The Divided Self are similar to Bleuler24 and Kraepelin.25 He presents the persons with schizophrenia as fundamentally alienated and as experiencing “a rent in his relation with his world … and a disruption of his relation with himself.” Such a person, according to Laing,26 does not and cannot feel “together with” others or “at home” in the world. He or she is unable to experience him or herself as “a complete person” (p17). In such states, it is unclear from moment to moment who or what one is, and the boundaries of self and other seem tenuous and unreliable. Moreover, one's world is terrifying as if it were “liable at any moment to crash in and obliterate all identity” (p45).

As an illustration of this, Laing26 offers the following excerpt from the speech of a person with schizophrenia:

“These thoughts go on and on, I am going over the border. My real self is a way down - it used to be just at my throat but now it has gone down further. I'm losing myself. It's getting deeper and deeper. I want to tell you things, but I'm scared. My head is full of thoughts, fears, hates, jealousies. My head can't grip them; I can't hold onto them…” (p151).

Focusing even more intently on the psychological experience of schizophrenia, Boss27 suggested that schizophrenia involves the experience of an “encroachment” on one's “ability to be responsive and open to what is encountered …. First they cannot open themselves fully to the meaningful address of what they encounter … so that they cannot respond with all their faculties to the normally accepted significance … of those things and events. Second they are unable to maintain a free stance vis-à-vis their perceptions of what they encounter” (p235). In view of this degree of personal destabilization, Boss27 regarded schizophrenia as the “… radically incomplete manifestation of the free and self-reliant selfhood that normally characterizes human beings. Therefore, schizophrenia is an illness that can be characterized only negatively …” (p236).

As an illustration of this, Boss27 offers the following excerpt from the speech of a person with schizophrenia:

“What should I do with a clock? I must look at it all the time… Am I myself not a clock? One is so engrossed in looking at the clock and loses the thread to oneself. Because I am myself a clock, everywhere in me, because it is always so confused… it is a running away from oneself …” (p228–229).

Like Bleuler24 and Kraepelin,25 Laing26 and Boss27 remark upon the disordered nature of psychic life in the throes of schizophrenia. Boss27 in particular echoes the earlier sense of radical incapacity and loss, and his account portrays a self that finds itself overwhelmed by what it perceives and encounters. Laing,26 however, seems to have a finer feel for what it is like to be that self. It is thus Laing26 who begins to articulate what the sense of self amid schizophrenia might entail: alienation, incompletion, and terror. In other words, whereas Boss27 speaks mostly of loss and incapacity, Laing26 helps us to begin to see a life interpreting and responding to its own incipient dispersion. Laing26 thus allows us to regard the person undergoing schizophrenia as something more than a site where symptoms emerge and collide. In fact, his account allows us to still recognize a reflexively aware subject suffering from and struggling with a fate that remains very much his or her own.

Views of Self-experience in Schizophrenia From Psychoanalysis

Psychoanalysts also have noted that persons with schizophrenia experience and openly report a diminished sense of identity along with tenuous boundaries between self and other.28,29 Freud30 asserted that schizophrenia occurs when persons fully detach themselves from the world and refocus all their psychic energies upon themselves. In this state, the self is essentially disengaged from the world and trapped in an exclusive self-relation. Anything other than the self is experienced as lacking affective valence to the point that all consensually valid meaning is threatened.

Importantly, if Freud's account is correct, psychoanalytic treatment would prove impossible for people with schizophrenia because they presumably could not form sufficient relationships with analysts. Several psychoanalysts resisted this implication, however, which led them to develop a deeper understanding of the fate of self-experience in schizophrenia. In particular, as analysts sought to treat schizophrenia, they encountered persons experiencing profoundly fractured identities who longed for closeness. On the basis of these findings, some presented schizophrenia in terms of a desire for and terror of connection with others (eg, Fromm-Reichmann31, Searles32, Sullivan33, Wexler34). Others suggest, in a complementary manner (eg, Bak35, Bion36), that schizophrenia involves experiences of emptiness and an inability to make meaning. In fact, some asserted that persons with schizophrenia were terrified that if meaning coalesced, a catastrophe would ensue, which would destroy either the individual with schizophrenia or the person with whom they were engaged. Despite their needs for love and closeness, persons with schizophrenia, according to this model, experience a world they need to avoid and even shield from their potentially destructive presence. Summarizing this and other work, Frosch37 suggests that persons with schizophrenia continuously sense that their basic capacity for self-experience is on the verge of destruction.

Like Laing's26 observations, psychoanalytic views of schizophrenia thus offer a feel for the illness's first-person dimensions. Schizophrenia is portrayed as involving an experience of exile from oneself. Once again we find a self that experiences anxiety in the face of others, although here, we find a self that experiences itself as unequal to the task of containing its own affects. Psychoanalytic literature thus portrays self-experience in schizophrenia in terms of (a) a longing for connection with others, (b) a simultaneously felt terror of social encounters, and (c) a self unable to successfully respond to emotionally provocative and demanding events.

As an illustration of this, Frosch37 offers the following excerpt from the speech of a person with schizophrenia:

“I become everything I experience to a point where it ultimately resolves into a state of considering myself the universe. I can open myself completely. My mind withdraws from anything that is directly dangerous to my body …. It means my sense of identify is expanded and there is no longer a me…” (p261).

Consistent with this, Wexler34 quotes an individual with schizophrenia as reporting:

“Nothing seems to have any permanence. I guess this is rubbish and ridiculous but I mean to say is I am losing my integrity …. I have placed myself in a highly insecure position and I think slowly I am losing my mind … if I ever had any sense of being. But it is all a very slow gradual subtle process …” (p280).

Fromm-Reichmann31 similarly offers the following quote from a therapy encounter:

“I warned you against becoming friendly with me. I told you you'd find out that I am an unbearably hostile person. Do you think it pleases me to behave that way? I assure you it does not. Why then do you trespass that way by forcing me to let you see what I'd rather not see myself …” (p188).

Views of Self-experience in Schizophrenia From Psychosocial Rehabilitation

Psychosocial rehabilitation involves a wide range of transtheoretical interventions such as supported employment and training in social skills. Presently, it is the most commonly recommended form of nonpharmacological treatment for schizophrenia. Oriented toward skill and function enhancement, psychosocial rehabilitation considers how persons can develop and pursue personally meaningful goals and live reasonably full lives. Among its research projects are several longitudinal studies of recovery processes,38 which consider multidimensional outcomes as well as the personal and social context in which illness and recovery occurs.17

Given its common focus on personal meaning in recovery, psychosocial rehabilitation research is explicitly concerned with schizophrenia's first-person dimensions. Some studies present persons who find themselves alienated from their social worlds and who manifest enormous desire for closeness as well as deep sensitivity to rejection.39 Others contain multiple references to persons who experience little sense of agency and who struggle to distinguish themselves from their illness.40–43 Considered longitudinally, these studies portray persons who feel eclipsed by their illness, sometimes to the point of being little more than an amorphous disturbance, an experience that recalls the portraits of ruined subjectivity noted above.

Thinking generally about these and similar phenomena, Davidson17 suggests that the experience of severe mental illness, and presumably schizophrenia in particular, does not only merely involve alienation and uncertainty but also a loss of authority with regard to one's sense of self. Such persons, he writes, may have stopped seeing themselves as “somebody, somewhere about whom a story might be told” (p211). As a result, they risk living a life in which they are invisible to themselves as protagonists.44 Finally, it is worth noting that the rehabilitation literature emphasizes that persons with schizophrenia, as is true with others without schizophrenia, constantly construct stories that contextualize self-experience. This propensity throws into relief how a given person finds himself or herself in the course of his or her life. It is unsurprising, therefore, that psychosocial research proceeds with the first person more firmly in mind than the perspectives noted thus far. That said, its observations complement many we have seen. On this view, persons with schizophrenia find themselves socially alienated, unable and sometimes unworthy to influence the course of their lives, and longing for connection but terrified of rejection.

As an illustration of this, Davidson17 quotes the words of Deegan, a person with schizophrenia, whose personal analyses of her condition have been highly influential among rehabilitation professionals:

“The professionals call it apathy and lack of motivation. But they don't understand that giving up is a highly motivated and highly goal-directed behavior. For us giving up, refusing to hope, not trying, not caring; all these were ways to protect the last fragile traces of our spirit and our selfhood from undergoing another crushing” (p153).

Views of Self-experience in Schizophrenia From Phenomenology

Other theorists with strong links to German and French philosophy and psychiatry have studied the structures of consciousness in schizophrenia. For example, Minkowski45 has suggested that schizophrenia involves a loss of “vital contact with reality” due to a persistent lack of ongoing, temporal syntheses, which leaves persons without enough integrated experience to sustain a sense of self. Having lost touch with the “moving stream which envelops us at all points and constitutes the milieu” of everyday life, such persons do not “know how to live” (p191). Said otherwise, “… although [the person with schizophrenia] knows where he is, he does not feel as if he is in that place … [T]he term ‘I exist’ has no real meaning for him” (p196).

Since Minkowski, phenomenological approaches to schizophrenia have been influenced by Blankenburg,46 who argued that schizophrenia renders self and world incomprehensible because it fundamentally undermines what he terms “common sense,” a capacity to gauge, without explicit, self-conscious reflection, what any given situation demands. He writes: “striking for those around the patient is that there is a withering away of a sense of tact, a feeling for the proper thing to do in situations, a loss of awareness of the current fashions … a general indifference towards what might be disturbing to others”46 (p306). Consequently there is the experience of a loss of continuity in things and events. In the words of Schwartz et al47: “If one inhabits a world in which the causal relations among objects and even the continuous identity of objects themselves is uncertain, unreliable and shifting, then it is difficult to speak to others in a way that would make sense” (p112).

Extending this logic, Stanghellini12 suggests that a loss of prereflectively operative, common sense would fundamentally disrupt self-experience in the context of relatedness. On this view, the problem becomes one of rote or stagnant interpretations of situations. Without a living connection to the world, one that establishes a dialogue between desire and the world's feedback, psychosocial dysfunction becomes less a lack of social skills than “… a defective dialectic between the two poles of the self: the individual characteristics embodied by the ‘I’ and the social demands embodied by the ‘me’” (p78). Moreover, Stanghellini12 notes, in the wake of these disconnects, that persons with schizophrenia are forced to confront the poverty of their grasp of things, which leaves them suspended in a “nothingness,” a state that seems to echo the observations of Laing.26

If a loss of some “common sense” undermines self-world interaction and sense of self in schizophrenia, one must also explore what undermines such a fundamental capacity. Mishara48 has presented 2 different approaches. The first he labeled “Apollonian,” following Nietzsche's dichotomization of personality types. This approach suggests that common sense withers under an inward gaze of radical intensity. For example, Sass18 suggests that sense of self in schizophrenia is not a matter of being less self-aware but “hyperreflexive” or self-aware to an extreme degree. In such a position, persons with schizophrenia attend to themselves with such an intense and fixed gaze that fragmentations result, which renders spontaneity and a grasp of basic life processes impossible. In effect, the person ceases to experience him or herself as a subject of awareness. It is worth noting that contra Freud the claim is not that interest has been redirected from the world to the self but that the self is lost in a radical self-absorption that eliminates the possibility of connection with others and consensual meaning.

Illustrating this concept of the hyperreflexive self, Sass18 offers a quote from the poet Artaud who may have suffered from schizophrenia:

“I felt the ground under my thought crumble, and I am led to consider the terms I use without the support of their inner meaning, their personal substratum. And even more than that, the point at which this substratum seems to connect with my life suddenly becomes strangely sensitive and potential” (p165).

A contrasting position is termed Dionysian, again using Nietzsche's dichotomy. Here, common sense fails because perceptual and automatic meaning processing are disrupted “from below.” The problem is not too much reflection but breakdowns in the preconscious processes that sustain connections between embodied feelings, judgments, and a world shared by others. Argued here is that Sass's and the Apollonian view in general fail to offer a model for how excessive self-awareness could become something that automatically persists over time. Consistent with this view, Parnas and Handest49 find an elemental lack of attunement to the world in schizophrenia, which makes basic engagement impossible. They describe, for instance, someone in the early stages of disorder, who “tended to lose the sense of whose thoughts originated in whom and [who] felt as if his interlocutor somehow ‘invaded him,’ an experience that shattered his identity and was intensely anxiety provoking” (p129). This parallels Mishara's50 suggestion that schizophrenia may involve disruptions in bodily systems that allow persons, without self-conscious effort, to suddenly attend to novel information, eg, by quickly turning around in response to an unexpected noise. In short, the claim is that such systems govern preconscious responses to worldly events, responses that simultaneously allow us to experience our bodies as more or less ready for action and thus “ours” or “mine” in the sense of at “our” or “my” disposal. When such systems are compromised, however, as they may be in schizophrenia, some “… may feel that their bodies are no longer their own or that they no longer exist through their bodies[,] as if they have lost all inner connectedness to their bodies …” (p131).

When set alongside other views, phenomenological analyses of schizophrenia distinguish themselves with their structural focus on the disorder's first-person dimensions. They not only observe anxiety, feelings of emptiness, and disordered psyches but also tie these phenomena to breakdowns in perceptual capacities, what many call “common sense.” This is of particular interest because it suggests that for some phenomenologists, Sass18 excepted, sense of self is less a matter of introspection than a phenomenon that accompanies, perhaps even arises out of worldly engagements.

As an example of a report of this experience Stanghellini12 offers the following excerpt:

“I feel lifeless. I have this ‘feelings of vagueness’ especially at sunset hours. I see colors as brighter. All sensations seem to be different from usual and to fall apart. My body is changing, my face too. I feel disconnected from myself, from my muscles, as if they were cropped up in an outer space …. It also occurs that in this state I get lost when I stay with others. What I lack is the common thought. I have nothing to share with them. In this way, the others become incomprehensible and scaring” (p126).

Views of Self-experience in Schizophrenia From Dialogical Psychology

A final view of alterations in self-experience that we wish to review is derived from dialogical psychology, which claims that self-experience emerges out of interactions among multiple self-facets animated in ongoing worldly engagements. With diverse roots, including the philosophical work of Kierkegaard51 and Nietzsche52 and the analyses of Bakhtin53 and Dewey,54 dialogism has both received experimental support from a range of contemporary studies55,56 and ventured a wide range of clinical innovations.57 According to dialogical psychology, it is a mistake to posit the existence of a stable or self-identical core self that underlies, let alone directs, the full range of human experience and action. Instead, it makes more sense to regard the self as an interanimating constellation of elements, or better still, moments (whose genesis is a braid of biological and social forces as well as personal experiences). For example, while eating lunch with a new lover after a stressful meeting, various self-facets might come into play: self-as-employee, self-as-hungry, self-as-customer, self-as-anxious, self-as-boyfriend/girlfriend, etc. In this view, then, sense of self arises out of interactions among (or “dialogues” between) these various facets in quite particular contexts. Importantly, the point is not that each self-facet generates its own self-experience. Rather, self-experience involves interaction or dialogue among the many, overlapping facets, none of which is the “real” self.

Using this model, it has been suggested that persons with schizophrenia may experience a general diminishment in self-experience due to difficulties sustaining dialogues among self-facets in worldly interactions.58–62 In particular, if the processes that allow different self-facets to engage and interanimate one another were imperiled, then dialogue, at least in part, would diminish, and this, in turn, would result in compromised self-experience. In order to render such phenomena concrete, 3 models of dialogical compromise have been proposed as well as 3 corresponding kinds of self-experience.59,61 First, if one self-facet dominates and orders most experience (eg, “self-as-in-danger” or “self-as-flawless”), then a monological self-organization would result, leading to a self-experience locked within one or a few facets. Alternatively, if no self-facets are able to meaningfully interact with another, an empty or barren state might follow in which a person might experience themselves as being more or less nondescript or even empty. Or, and this is the third model, without any order it also seems possible that the many, different aspects of self may speak at once in the manner of a cacophony, which would contribute to a sense of oneself as overwhelmed, lost, or highly anxious.

The following is an excerpt from the speech of a person with schizophrenia that illustrates the experience of a cacophonous self:

“I don't have to cry …. When I first stated feeling queasy is when I first saw an accident before that I was just on the road where they drove by and I got kind of sick out there and walking by this lady's house who used to be my diaper washer who visited Viet Nam but I was a mess when they said I assaulted her because that needle doesn't go around assaulting people… it may have something to do with me being in me but I would like to get it taken out”59 (p213).

This model of self-experience in schizophrenia has also funded the hypothesis that self-experience might be especially taxed by intimate interpersonal contact62 because contact of this sort seems to animate multiple self-facets. For instance, knowing someone might easily call forth amorous, competitive, envious, or empathic aspects of self that then have to be integrated in an organized conversation. Being known by another person also calls forth the matter of having to deal with how that person sees you (eg, as competitive, envious, inadequate, attractive). While such exchanges might result in different experiences if one lives through a monological, barren, or cacophonous self-organization, in each case it seems likely that rich, interpersonal contact would be experienced as a threat and intimacy avoided. And this, in turn, could lead to its own lines of self-experience such as abandonment and alienation, which might complement or even intensify the self-experiences associated with compromised intrapersonal dialogue.

As an illustration, Lysaker et al62 have offered the following excerpt from the speech of a person with schizophrenia:

“I'm just a speck … a speck on somebody's friendship or something. It's too late to change a lifestyle into a system or more. I mean to be with an individual and never leave the ground, a complete human being, I mean you get messed up over about interacting with others, seems like it swings both ways. If you feel like you've got nothing to contribute and it's not worth another person's time” (p85).

First-Person Experience in Schizophrenia: Points of Convergence and Divergence

Surveying the past 100 years, we would suggest that literature pertaining to self-experience in schizophrenia converges and diverges along 3 key points. First, when taken together, traditional psychiatric, existential, psychoanalytic, phenomenological, rehabilitative, and dialogical approaches to schizophrenia articulate a common finding, even if they present it in diverse ways. Many with schizophrenia experience themselves as having been diminished since the onset of their illness. In some sense or other, they find themselves less than they were, which is to say they feel less vital and less able to negotiate or even engage the world. Existential, psychoanalytic, phenomenological, rehabilitative, and dialogical approaches also observe that many interactions can prove threatening to those suffering from schizophrenia, and thus, some willfully avoid them in order to prevent their sense of self from being further degraded.

However, one should not allow this common finding to obscure notable differences among the approaches we have reviewed. First, there is disagreement regarding when and how diminishments in self-experience emerge. According to the rehabilitative and dialogical points of view, these difficulties can appear quite suddenly. Persons may have rich internal experiences only to have them fray with the onset of illness, resulting in a sense of self as diminished. Lysaker and Lysaker58 present a case study involving apparent healthy psychological function prior to onset, and multiple reports suggest the same.63 Phenomenological and existential models by contrast generally suggest that a lack of attunement (or common sense) may be at work long before the illness takes hold. And psychoanalytic models suggest that patterns of impaired interpersonal and self-relations also likely predate illness. Authors from the schools of phenomenology and psychoanalysis specifically suggest that a sense of self as diminished is the eventual manifestation of preexisting alterations in self-experience, which are already underway early in life and which are necessary for the development of the disorder during the tumult of adolescence and early adulthood. The claim is that a basic constitutional deficit prevents some children from building their identity within initial interactions with parental figures, and this leaves them with a self that cannot manage anxiety prior to illness.64 Minkowski,45 eg, suggests that the disharmony of person and world, so characteristic of many who suffer from schizophrenia, is present long before formal symptoms arise. In other words, prior to onset, one should find a life that has “evolved in fits and starts… not [as] a continuous line, supple and elastic but [as] one broken in several places” (p206). Similarly, Bovet and Parnas65 argue that from early on, basic attunement with world is lacking in persons with psychosis.

A related but even wider point of divergence concerns the degree to which one can expect persons with schizophrenia to recover a more integrated range of self-experience. The traditional psychiatry of Bleuler24 and Kraepelin,25 as well as phenomenological and existential views, suggest, at least at the theoretical level, that the reemergence of a less splintered, anxiety-ridden sense of self is relatively unlikely for those suffering from schizophrenia. Bleuler,24 Kraepelin,25 and many phenomenologists posit essentially irreversible processes at the root of schizophrenia. Laing26 does hold out for a better clinical understanding of persons with schizophrenia, but that is a different matter, and he says little about what might lead to health. Psychoanalysis, on the other hand, suggests that some kind of recovery is possible, though this involves reforming the self in the context of the relationship with the analyst. Bion,36 for instance, notes cases of persons who meaningfully recovered; but he suggests that this was made possible by a therapeutic relationship wherein persons learned to make meaning of daily life and to sustain mutual understanding with another person while managing intense feelings of rage. For Karon,66 recovery is also possible if those with schizophrenia internalize aspects of the therapist. He writes: “what changes the patient is (that) … the patient internalizes the therapist into the superego so that the patient treats him or herself in the kindly rational way the therapist would instead of the rigid and punitive way that most patients treat themselves based on early identifications” (p106).

Rehabilitative models hold out considerable hope for recovery. Beyond rejecting the claim that compromised self-experience necessarily predates illness, theorists from this vantage point generally believe that richer self-experience and improved function can follow greater participation in routine life. Bebout and Haris67 suggest that through basic work and the like, persons can find ways and reasons to engage the world that enrich self-experience. Davidson,17 as well as Roe and Ben-Yishai,41 suggest that directed reengagement allows persons to see themselves differently, reject stigma, and even conceive of themselves as having a life beyond the perimeters of their illness. This view is certainly consistent with a range of first-person accounts that detail not only a life of engagement before the illness but also an eventual return to fully meaningful engagement (eg, Deegan68 and Frese69).

Like the rehabilitation view, the dialogical approach does not believe that schizophrenia involves a catastrophic and irreversible disruption of the meaning-making capacities required for coherent and empowering self-experience. Rather, the suggestion is that schizophrenia entails inabilities to negotiate the intra- and interpersonal dialogues that lay the groundwork for sense of self, which nevertheless can be partially remedied through psychotherapy in conjunction with rehabilitation. The dialogical view thus shares with rehabilitation approaches the thought that directed and purposive interactions with others is beneficial, though on this view, the benefit also includes the reemergence of an ability to sustain, in social interactions, the kind of everyday, complex dialogues that sustain sense of self. With its emphasis on psychotherapy, the dialogical approach also overlaps with some psychoanalytic views. Both viewpoints hold that psychotherapy might help persons become more active meaning makers in their lives (eg, Bion36). However, the dialogical approach does not focus on the resolution of conflict or the management of abnormal affects. Instead, therapeutic interactions are oriented toward developing capacities for attending to and reflecting upon self-facets. And while those facets will include some tied to being ill, the ways in which the lives of clients are irreducible to their illness are also brought into the flow of self-facets that underwrites sense of self. Put generally, the goal is thus to reinvigorate dialogical capacity, much as, after an injury, physical therapy slowly strengthens physical capacities.23,61

Summary and Future Directions

Wide-ranging work on some of the first-person dimensions of schizophrenia suggests that this condition is linked to a sense of self as diminished, combined with grave anxiety in the face of worldly engagement. However, significant disagreements exist regarding whether these difficulties meaningfully predate the illness and whether recovery is possible and if so under what conditions. We would suggest that this points to at least 2 different possible programs of future research.

First, it is now widely recognized that among those who suffer from schizophrenia, more persons than not achieve some state of recovery. Longitudinal studies that assess self-experience could, for instance, speak directly to the issue of whether difficulties with interpersonal connection and attunement indeed predate the onset of illness and/or are generally resolved because symptoms remit and function later improves. Emerging literature suggests many with schizophrenia often recover rich and coherent forms of self-experience (eg, Young and Ensing 43, Roe and Davidson44, and Lysaker et al70). This certainly raises the question of not only how often and to what degree this occurs but also what clinical or neurocognitive changes precede and proceed these changes. Longitudinal assessment of self-experience along with other indicators of neuropsychological and interpersonal function have the potential of indicating the manner in which changes in brain function and social role are cued to loss and recovery of sense of self. Do alterations in self-experience predate by weeks, months, or years the development of other aspects of illness? In addressing this and other questions, it is important that longitudinal assessments of self-experience should not only include responses to standardized instruments but also qualitative and newly emerging quantitative ways to assess the richness and depth of personal narratives in schizophrenia.71 Certainly, detailed personal analyses involving self-experiences from persons suffering from the illness should be sought because they could offer invaluable insights into these issues.

A second set of research that may prove highly relevant involves the development of psychological, psychosocial, and other therapies. Do, for instance, the different forms of self-disturbance noted by dialogical theory point to different kinds of interventions? Do persons with monological forms of self-disturbance benefit more from cognitive interventions while persons with barren states respond better to humanistic or behavioral therapies? If alterations in self-experience are tied to neurcognition, do interventions such as cognitive remediation which lead to improved memory and attention72 also lead to objective changes in self-experience? And if so, are such changes a mediating factor in subsequent improvement in psychosocial function? Lastly, a better understanding of possible phenomenological challenges to self-experience might also point to different kinds of rehabilitation interventions that help some cope with the complexities of intersubjectivity.

In sum, while literature from many perspectives has explored self-experience in schizophrenia, one barrier to the creation of a larger synthesis and application of this work is that disagreements exist regarding views pertaining to the emergence of persistence of any alterations in schizophrenia. Longitudinal research coupled with exploration of the possible treatment implications of these views has the possibility of more fully mapping, in an empirical manner, the first-person dimension of this illness, thereby leading to a more thorough account of dysfunction and recovery, which can only enrich existent accounts of the biological and social forces involved in schizophrenia.

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